Overcoming Telehealth Barriers and Engaging Older Adults in Virtual Care

The COVID-19 pandemic magnified the importance of telehealth as a vital component of patient care. However, some older adults may not have been able to take full advantage of virtual care in the same way as others for a number of reasons.

This fact sheet examines and highlights the barriers that may prevent some older adults from participating fully in telehealth and offers practical strategies that healthcare providers can implement to address these issues.

Telehealth barriers for older adults

Various factors have been identified as potential barriers to telehealth for older adults. These barriers include technological issues, medical conditions and life circumstances. Alone or combined, these may place older patients at a digital disadvantage.

1. Lack of access to technology

Telehealth relies on technology for the transfer of information between parties. This can be problematic for some older adults who may not have access to the necessary electronic devices and services.

According to the 2020 Office of National Statistics figures on internet users, almost half (46%) of the UK population of people aged 75 years and over have never used the internet.

In the absence of these technologies, telehealth is limited to telephone calls, which may work for simple services (such as medication reviews) but has limitations for more in-depth care.

2. Lack of experience with technology

Even when older adults have access to technology, problems may arise when patients are inexperienced in using it. This can lead to difficulties in troubleshooting issues that arise, or more generally, adapting to digital communication.

According to the UK Consumer Digital Index 2020 report, “An estimated 9 million (16%) are unable to use the Internet and their device by themselves.”

3. Hearing, vision, and/or communication impairments

Gradual deterioration in hearing and vision are normal processes of ageing, which can make communicating via technology difficult. An article published in the BMJ, “Depression in older adults” (2018), notes that “hearing loss is almost universal amongst older adults.” An NHS England report, “Action Plan on Hearing Loss” states that “5.3 million older people (aged over 65) in England have a hearing loss.”

Additionally, because telehealth encounters occur outside of the controlled setting of the consultation room, the potential for noise, distractions and missed visual cues may be greater. This can impede both patient and provider comprehension.

4. Cognitive issues

Unfortunately, cognitive impairment is a reality for many older adults. Research conducted by the Care Policy and Evaluation Centre (CPEC) at the London School of Economics and Political Science on behalf of Alzheimer’s Society identified that in 2019 there were over 850,000 people with dementia in the UK. This represents 1 in every 14 of the population aged 65 years and over.

However, a paper by Lam K et al, “Assessing Telemedicine Unreadiness Among Older Adults in the United States During the COVID-19 Pandemic”, explains that the minor cognitive changes that naturally occur with ageing should not prevent older adults from using telehealth services. Many individuals who have a mild cognitive impairment “can successfully learn new skills, especially if they use compensatory strategies.” Such strategies might include appointment reminders, step-by-step instructions for using the telehealth application or seeking a family member’s help using such applications.

5. Socioeconomic factors

Socioeconomic status across society can affect a patient’s willingness or ability to participate in telehealth encounters. For example, income and education levels might play a role in whether patients have access to technology or experience in using it. Older adults who have concerns about costs associated with mobile phone plans and data charges might prefer telephone-only appointments. In many circumstances, telephone-only appointments can be useful. However, the inability of a practitioner to note visual cues from a patient means the scope of such consultations may be limited.

Socioeconomic status can also affect other barriers that contribute to telehealth difficulties, such as hearing and vision loss if patients lack access to care and/or cannot afford assistive products or devices.

Telehealth strategies for older adults

Although not all older adults experience telehealth barriers, those who do are unable to enjoy the full benefits, or any benefits, of virtual care. The result of this disparity is not yet fully understood, but the consequences could be significant. Serious health conditions might go undetected, or there may be a delay in diagnosis and necessary treatment. Ultimately, in some situations, treatment may never be provided.

Many of the issues related to telehealth disparities are complex and require broad public health approaches and systemic solutions. However, healthcare providers who treat older adults can also implement meaningful strategies to help this cohort of patients have successful experiences with virtual care. These strategies should be considered before, during and after telehealth encounters.

1. Before telehealth encounters

• Raise awareness surrounding the availability of telehealth services, talk to patients about the benefits and limitations of virtual consultations. Assure patients that you, as the healthcare provider, are dedicated to providing high-quality care during telehealth encounters.
• Consider contacting or having a staff member contact patients before telehealth appointments to take them through the process of using the telehealth application. This will provide an opportunity to test their ability to connect and allow you to answer any questions the patient may have. This could save time during the actual consultation.
• Develop written instructions that guide patients step-by-step through using the telehealth application. Include screenshots associated with each step of the process.
• Evaluate the space in which you conduct telehealth consultations to ensure it has adequate lighting, is devoid of distracting items, offers privacy and minimises the potential for noise or other disruptions.
• Invest in quality telehealth equipment, such as cameras and microphones, to optimise communication with patients. Consider using a headset with a microphone to improve audio quality and reduce background noise.
• Explain to patients the safeguards you have put in place to protect them and their health information.

2. During telehealth encounters

• Consider using a framework to help guide appointments, engage patients and ensure consistency of care. An example of a framework is the Institute for Healthcare Improvement’s “What to say during telehealth visits with older patients”.
• Where possible, encourage patients to use video to maximise the benefits of telehealth encounters. However, be sensitive and respectful of patients’ limitations and preferences. Additionally, if video is used, determine whether captioning is available to enhance communication.
• Confirm that patients are in a quiet and private location at the beginning of the telehealth appointment and ask if they can hear you and see your face.
• Acknowledge that telehealth encounters can seem awkward and unnatural at the outset. Let patients know that you will verbally verify their understanding of the information or clarify any visual cues that indicate misunderstanding or frustration.
• Suggest that patients use a headset or headphones to improve their ability to hear. For patients who have hearing aids, confirm they are using them.
• Speak clearly and concisely while looking into the camera. Do not raise your voice or yell as the technology might distort the sound.
• Watch for signs that patients are not following the conversation or do not understand you. Address these issues early to avoid confusion and misunderstanding. For example, encourage patients to increase speaker volume, put on their glasses or use an available headset. Repeat information as needed, or rephrase what you’re saying if a patient still seems confused.
• Consider recommending an interpreter if short-term solutions do not improve patients’ ability to see, hear or understand what you are saying.
• Use a comprehension technique such as the teach-back method to confirm that patients understand the information you have conveyed.
• If a practitioner is not satisfied that the virtual consultation has met the patient’s needs or has identified that the patient requires an examination or further discussion, the doctor should offer the patient a face-to-face consultation. This decision should be recorded in the patient’s medical record. Please refer to the GMC’s flow chart in “Remote consultations”.

3. After the telehealth encounter

• Provide a written summary of the telehealth appointment, including key points, treatment recommendations and instructions. Make sure the summary is clear, concise, easy to read and understand.
• Ask patients to provide feedback on their telehealth experience. Constructive feedback can help identify potential issues with the platform, the process and communication. The provider and staff members can then use this information as the basis for quality improvement initiatives.

Please also refer to the PMP fact sheet, “Bridging the Digital Divide: Creating a Personalised Telehealth Experience”.

In summary

Whilst some older adults may experience barriers to telehealth, including lack of access to technology; inexperience with technology; hearing, vision, and/or communication impairments; cognitive issues; and socioeconomic factors. These barriers can hinder the provision of necessary care and treatment, particularly when in-person care is limited.

Healthcare providers who have a cohort of older-patients can address some of these issues using strategies before, during, and after patient encounters. Proactive approaches to identifying and resolving telehealth barriers can optimise virtual interactions for patients and help address disparities in care.

If you have any queries or concerns surrounding the issues raised in this fact sheet, please do not hesitate to call the PMP medicolegal helpline. The helpline is open 24/7, and contact details can be found on your policy documents or customer card.